Sodium Bicarbonate Framing
Objective: Stop dumping bicarb into every arrest, and keep it for the poison/hyperK cards that actually name it.
Why This Is Hard
The arrest bag has bicarb and it feels like doing something. AHA 2025 ALS: routine sodium bicarbonate is not recommended in cardiac arrest. Special circumstances still list it for certain poisonings and selected metabolic crises.
- Do not open bicarb because the arrest is going poorly.
- TCA / sodium-channel blocker overdose with wide QRS is a classic protocol use — alongside airway and benzos for seizures.
- Bicarb precipitates with calcium. Flush the line.
Field Rules (Education)
- Not routine in arrest. High-quality CPR, defibrillation, epinephrine timing, reversible causes.
- Sodium-channel block (TCA teaching): wide QRS, unstable — bicarb is a common protocol. This site does not publish mEq.
- HyperK: bicarb is a maybe if they are acidotic per protocol — not instead of calcium for ECG toxicity.
- Crush / prolonged down may appear on some cards. Follow yours.
Field Pitfalls
- Bicarb in every PEA.
- Same line as calcium.
- Bicarb instead of airway in a seizing TCA.
Practice
60-second drill
Partner: (1) asystole 15 minutes, no tox story; (2) empty TCA bottle, wide and hypotensive, still a pulse. Bicarb yes/no.
Related: Toxidromes, Calcium.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; protocol still wins
- AHA 2025 Part 9: Adult ALS — routine bicarb not recommended in arrest
- AHA 2025 Part 10 — selected toxicologic uses remain protocol-based
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Street decisions from this lesson only. After you check, the key is highlighted. Education practice — not a certification exam.